What incision and operative steps are recommended for open umbilical hernia repair?

Umbilical Hernia Repair: Incision and Operative Steps

For adult umbilical hernias, use a single curved intra-umbilical incision (1.5-2.5 cm) that provides excellent cosmesis while allowing complete hernia repair, with mesh reinforcement mandatory for defects >2-3 cm to prevent the 42% recurrence rate associated with primary suture repair alone. 1, 2, 3

Incision Selection

The periumbilical or intra-umbilical curved incision is the preferred approach, offering superior cosmetic outcomes with no externally visible scar postoperatively. 2

• Incision length: 1.5-2.5 cm average, placed within the natural umbilical folds 2
• Avoid midline incisions when possible, as non-midline approaches demonstrate significantly lower incisional hernia rates in high-quality evidence 4
• The transumbilical approach allows direct access to the fascial defect while preserving umbilical aesthetics 5

Operative Steps: Algorithmic Approach

Step 1: Exposure and Sac Identification

• Make the curved intra-umbilical incision through skin and subcutaneous tissue 2
• Identify and dissect the hernia sac from the fascial defect margins 1
• Free the sac circumferentially from the edges of the fascial defect 1

Step 2: Defect Size Assessment and Repair Strategy

For defects <2-3 cm:

• Primary suture repair with non-absorbable sutures is acceptable in low-risk patients 1, 3
• However, mesh reinforcement should be strongly considered even for smaller defects, as institutional data shows recurrence rates of 4.9% with tissue repair alone 3

For defects ≥3 cm:

• Mesh repair is mandatory to avoid the 42% recurrence rate associated with primary suture alone 6
• The mesh must overlap the defect edge by 1.5-2.5 cm in all directions 6

For patients with BMI ≥30 kg/m²:

• Perform mesh hernioplasty regardless of defect size, as obesity is an independent risk factor for recurrence 2

Step 3: Mesh Placement Technique (When Indicated)

For defects <3 cm:

• Insert a cone-shaped polypropylene mesh into the extraperitoneal plane 1
• Secure with non-absorbable sutures to the fascial edges 1
• No fascial closure is required when using the cone technique 1

For defects >3 cm:

• Create an extraperitoneal space by dissecting between fascia and peritoneum 1
• Place a flat polypropylene mesh as a sublay (retromuscular/preperitoneal position) 1
• The sublay position is preferred as it provides superior strength and lower recurrence rates 4
• Mesh can be fixed with transfascial sutures or tackers 6

Alternative minimally invasive approach (eTEP technique):

• The enhanced-view totally extraperitoneal approach places mesh outside the abdominal cavity via a minimally invasive technique 7
• Uses inferior port positioning with caudal-to-cranial dissection 7
• Mean operative time 101.8 minutes, but offers excellent outcomes with no recurrences in recent series 7
• Requires higher surgical expertise but is highly reproducible once mastered 7

Step 4: Fascial and Skin Closure

• Do not attempt to close the fascial defect when using mesh repair, as tension-free technique is the goal 1
• For primary suture repair: close the fascial defect with non-absorbable sutures using continuous technique (faster than interrupted, with equivalent outcomes) 4
• Excise excess umbilical skin at a fixed length to maintain natural contour 5
• Suture fascia and dermis vertically over 15 mm length for optimal cosmesis 5

Anesthesia Considerations

Local anesthesia is the preferred approach for open umbilical hernia repair, offering multiple advantages over general anesthesia. 1, 6

• Fewer cardiac and respiratory complications 6
• Shorter hospital stays and lower costs 6
• Faster recovery times 6
• All 49 of 54 patients in one series successfully underwent repair under local anesthesia 1

Expected Outcomes and Follow-Up

• Postoperative pain: Typically mild to moderate; no patients should experience severe pain with proper technique 1
• Hospital stay: Average 1.8-3.9 days depending on technique 2, 7
• Complications: Superficial wound infection (7-15 patients in series) responds to oral antibiotics without mesh removal 1, 2
• Recurrence with mesh: Essentially 0% at 2-6 year follow-up when proper technique is used 1, 2
• Recurrence without mesh: 4.9-19% depending on defect size and patient factors 4, 3

Critical Pitfalls to Avoid

Inadequate mesh overlap: Failure to achieve 1.5-2.5 cm overlap in all directions leads to recurrence 6

Using primary suture for defects >3 cm: This results in a 42% recurrence rate and should be avoided 6

Attempting fascial closure under tension: When using mesh, do not close the fascial defect—this defeats the purpose of tension-free repair 1

Ignoring BMI in surgical planning: Patients with BMI ≥30 kg/m² require mesh regardless of defect size 2

Inadequate extraperitoneal dissection: Insufficient space creation prevents proper mesh positioning and increases recurrence risk 1

Choosing midline extraction sites in laparoscopic cases: This significantly increases incisional hernia rates and should be avoided 4